A Perioperative Care Display for Understanding High Acuity Patients

Background  The data visualization literature asserts that the details of the optimal data display must be tailored to the specific task, the background of the user, and the characteristics of the data. The general organizing principle of a concept-oriented display is known to be useful for many tasks and data types. Objectives  In this project, we used general principles of data visualization and a co-design process to produce a clinical display tailored to a specific cognitive task, chosen from the anesthesia domain, but with clear generalizability to other clinical tasks. To support the work of the anesthesia-in-charge (AIC) our task was, for a given day, to depict the acuity level and complexity of each patient in the collection of those that will be operated on the following day. The AIC uses this information to optimally allocate anesthesia staff and providers across operating rooms. Methods  We used a co-design process to collaborate with participants who work in the AIC role. We conducted two in-depth interviews with AICs and engaged them in subsequent input on iterative design solutions. Results  Through a co-design process, we found (1) the need to carefully match the level of detail in the display to the level required by the clinical task, (2) the impedance caused by irrelevant information on the screen such as icons relevant only to other tasks, and (3) the desire for a specific but optional trajectory of increasingly detailed textual summaries. Conclusion  This study reports a real-world clinical informatics development project that engaged users as co-designers. Our process led to the user-preferred design of a single binary flag to identify the subset of patients needing further investigation, and then a trajectory of increasingly detailed, text-based abstractions for each patient that can be displayed when more information is needed.     

Results of gastrojejunal anastomotic technique designed to reduce stricture

BackgroundThe incidence of strictures developing after gastrojejunostomy has been reported to range from 3% to 31%. We found an unacceptably high stricture rate (13%) using a 21-mm circular stapler. Attempts to use the 25-mm circular stapler were frustrated by disparities between the size of the instrument and the patient's anatomy. We, therefore, modified the technique to accomplish the anastomosis with the linear stapler and hand sewing (LSA) at community hospitals in Southern California.MethodsA total of 124 anastomoses were accomplished with the circular stapler (CSA) followed by 100 anastomoses using the LSA technique. Drains were used routinely with the CSA technique but were used only selectively with the LSA technique. Stricture was defined as that requiring endoscopic dilation for symptoms. Leaks were confirmed radiologically or surgically, and bleeding was defined as the need for transfusion. Our analysis used the Student t test and Fisher's exact test, with P <.05 considered statistically significant.ResultsNo patient died. The LSA technique was faster and resulted in significantly fewer postoperative strictures and complications compared with the CSA technique.ConclusionThe results of our study have shown that the LSA technique, as described, is preferable to the CSA technique.     

The information needs of women newly diagnosed with breast cancer

Nurses can play a key role in patient education, including providing patients with useful and approrate information Rather than focusing on the process of education or information giving by nurses, this study places emphasis on the content of that information by taking the patients'perspective and asking the patients themselves what particular types of information are perceived as important at a specific point in time The aim of the study was to explore what particular types of information were important to women newly diagnosed with breast cancer, to enable nurses and other health care professionals to utilize their time as effectively as possible and provide a high-quality service to individuals in their care Women with breast cancer (a mean of 2 5 weeks from diagnosis) were interviewed and asked to compare items of information The items of information were presented m pairs and the women stated a preference for one item in that pan- Thirty-six pairs were presented in total The analysis involved the use of a Thurstone scaling model, which allowed rank ordermgs, or profiles of information needs, to be developed, reflecting the perceived importance of each item Information about the likelihood of cure, the spread of the disease and treatment options were perceived as the most important items of information at the tune of diagnosis Other information needs, in order of descending priority, included information about the risk to family, side-effects     

Ethnic factors in voluntary and compulsory admissions

Socio-demographic and clinical aspects of compulsory and informal admissions to general adult psychiatry wards over a two-year period are compared. In addition, Afro-Caribbean patients are compared with white UK-born patients. Relative rates of admission are examined. The study confirms other reports of greater than expected compulsory admissions of Afro-Caribbean patients and pays particular attention to the circumstances preceding compulsory entry to hospital and the persons and agencies involved in that process.     

CT guided interstitial therapy of pancreatic carcinoma

We describe the use of percutaneous CT guidance for localization and placement of 192Ir sources into a patient with pancreatic carcinoma. We have shown the feasibility of this procedure and the lack of complications which are probably due to minimal damage to tissue involved. Computed tomography is ideally suited for percutaneous implantation because it provides the most accurate method for needle placement within the abdomen.     

The acquisition of cytokine responsiveness by murine B cells: a role for antigen and IL-5 in the induction of IL-2 receptors.

The mechanism whereby small resting (high buoyant density) murine B cells are induced to express interleukin-2 receptors (IL-2R) and to respond to IL-2 was addressed by staining with anti-IL-2R alpha and -IL-2R beta monoclonal antibodies (mAb), and using receptor-specific cDNA probes. Resting B cells expressed undetectable levels of both IL-2R alpha and beta chains on their surface and did not respond to IL-2, even at supra-physiological concentrations. Sepharose-coupled, but not streptavidin-cross-linked, plastic-adsorbed or soluble, anti-mu up-regulated the expression of IL-2R alpha and beta chains and mRNA to levels comparable to those seen in activated T cells. Anti-mu-stimulated B cells responded to IL-2 by incorporation of [3H]thymidine and high rate immunoglobulin (Ig) secretion. Both IL-5 (at optimal concentration) and suboptimal lipopolysaccharide (LPS; 20 ng/ml) induced surface expression of IL-2R alpha. The level of expression induced by IL-5 was equivalent to that on anti-Ig-activated B cells. Neither stimulus induced detectable expression of IL-2R beta, and neither induced B cells to respond to IL-2. IL-2R alpha expression was strongly enhanced, and low levels of IL-2R beta staining and mRNA were induced by the combination of LPS plus IL-5. LPS+IL-5-treated B cells responded to IL-2 by Ig secretion. This indicates that B cells regulate their responsiveness to IL-2 similarly to T cells, via the combined level of expression of IL-2R beta and IL-2R alpha. The synergy between IL-5 and LPS for B-cell responses shows a requirement for complementary stimuli such as would be provided by cytokines, and either cellular interaction or antigen recognition in regulation of B-cell responsiveness to IL-2.     

Lidocaine 0.5% spinal anaesthesia: a hypobaric solution for short-stay perirectal surgery

The efficacy of subarachnoid injection of 8 ml lidocaine 0.5% was assessed in ten outpatients having perirectal surgery in the jackknife position. This solution is hypobaric, with a baricity 0.9985 +/- 0.0003 (mean +/- SD). Injections were made with the patient in the surgical position (with the upper torso at a 15 degrees downward inclination). Sensory level was tested by pinprick. Times to two-segment regression, to complete resolution of sensory analgesia, to urination, and to discharge from the recovery room were recorded. All injections produced effective anaesthesia for surgery. Lidocaine 0.5% behaves clinically as a hypobaric solution. Dermatomal levels remained low (T11 to L5) while the patients were in the surgical position (head down), but rose two to six dermatomes if the patient's head was elevated after surgery. Time to two-segment regression was 97 +/- 36 min, time until regression to S1 was 116 +/- 22 min, time to complete resolution of sensory blockade was 151 +/- 23 min, time to urination was 197 +/- 64 min, and time to discharge from the recovery room was 205 +/- 45 min. Lidocaine 0.5% provides effective spinal anaesthesia of short duration appropriate for outpatient surgical procedures. Dermatomal sensory spread of anaesthesia, and our measurements of specific gravity, indicate that this solution is hypobaric. It appears that changes in position can alter the spread of analgesia for at least one hour after injection and, thus, we caution against elevating the patient's head in the immediate postoperative period.